Invisible scars: mental health programming is crucial in humanitarian response

Across modern conflict zones, psychological trauma has become an enduring and often invisible consequence of war. As violence escalates globally, the mental health toll on affected populations has reached unprecedented levels. For humanitarian practitioners, addressing psychological harm is no longer optional or secondary: it must be integrated into emergency response from the outset.

Trauma and distress can cripple people’s ability to seek help, protect their families, and recover, making early action as urgent as food or shelter. In protracted crises, ‘later’ may never come, and untreated harm can become lifelong. Humanitarians, including local actors, are on the front lines, trusted by communities and able to weave psychosocial care into health, protection and aid delivery. But conviction is not enough: funders must treat mental health as core to survival, not an add-on. Acting early protects lives, dignity and the path to recovery.

Psychological warfare: an evolving threat

What was once a side effect of war is now an explicit tactic. Psychological warfare is defined as the planned use of psychological tactics to weaken an enemy’s morale and cause mental stress. No longer confined to the battlefield, it is now deployed in civilian spaces: subtly, persistently and globally. In Ukraine, civilians face what UN coordinator Matthias Schmale described as ‘psychological terror’ alongside physical destruction. In the Middle East, devices like exploding pagers distributed among combatants have caused psychological destabilisation in the civilian population, even for those who have not been physically harmed. These examples underscore the evolving nature of conflict, where the battlefield increasingly targets the human mind.

Gaza: a case study in mass trauma

The Gaza Strip exemplifies the intersection of physical violence and psychological devastation. A study concluded that 54.7% of Palestinian children have experienced at least one traumatic event, with nearly half exposed specifically to war-related trauma. According to recent reports, 96% of children in Gaza fear imminent death, and nearly half believe they will not survive the war. The report states that the children exhibit symptoms of acute psychological distress including anxiety, aggression and withdrawal. Women and girls additionally face unique risks. Approximately 150,000 pregnant women live in crisis conditions, while one million women and girls have been displaced. At the same time, food poverty affects 95% of pregnant and breastfeeding women, severely compromising maternal and infant health. As famine looms, the trauma intensifies. This emotional toll reflects a broader mental health crisis, with more than half the population in Gaza and the West Bank reporting symptoms consistent with depression or post-traumatic stress disorder.

Trauma beyond Gaza: a global crisis

Other contexts reflect similar patterns. In the Rohingya refugee camps, nearly one million stateless individuals live in protracted displacement. In early 2025, over 14,000 children were acutely malnourished. In Syria, 16.5 million people need humanitarian aid, with children and youth showing long-term trauma from displacement and loss. Sudan’s conflict has displaced over 11 million people and caused a breakdown in societal structures, including education, contributing to high rates of post-traumatic stress disorder, anxiety and depression among youth in areas such as the River Nile state.

Effective mental health interventions

Despite the scale of need in the humanitarian sector, effective psychological interventions exist. Cognitive behavioural therapy (CBT) and teaching recovery techniques have emerged as some of the most commonly applied psychosocial interventions. These interventions are particularly favoured for their structured, skill-building frameworks that target anxiety, depression and trauma-related symptoms. CBT has been adapted to suit particular contexts. For example, in the Occupied Palestinian Territories (OPT) and among Palestinian refugees, CBT-based interventions were delivered in family and group-based formats that leveraged existing community support networks, making them more acceptable and accessible.

Another widely used method is Narrative Exposure Therapy (NET), which has proven especially effective with refugee populations and in war-affected areas. NET guides individuals through a chronological retelling of their traumatic experiences until the memories no longer provoke significant anxiety. NET is specifically designed to help survivors process complex trauma by integrating fragmented memories into a coherent narrative. In some cases, NET has been adapted to suit local contexts. In Jordan, for example, the intervention was delivered by a therapist who shared the same national origin, language, religion and cultural background as the refugees. This shared identity helped foster trust and made participants more willing to engage, compared to working with ‘outsiders’ who might be perceived as authority figures.

Eye Movement Desensitisation and Reprocessing (EMDR) is another structured, evidence-based therapy that facilitates trauma recovery by stimulating bilateral brain activity, typically through guided eye movements, alternating taps, or auditory tones, while recalling distressing memories. One widely used form of bilateral stimulation is the ‘butterfly hug’, a self-administered technique where individuals cross their arms over their chest and alternately tap their shoulders, mimicking the gentle flapping of butterfly wings. This technique has been adapted for group settings and children, particularly in humanitarian contexts.

In the OPT, an adapted EMDR butterfly hug protocol was implemented with children in refugee camps and found to reduce post-traumatic and peritraumatic stress symptoms while increasing resilience. To enhance accessibility and cultural sensitivity, the protocol was significantly modified by omitting cognitively demanding components such as ‘negative and positive cognitions, the validity of cognition scale, and the body scan’, elements that may be less appropriate for young children or those unfamiliar with Western psychological frameworks. Instead, the intervention centred on the butterfly hug, a non-invasive, self-administered form of bilateral stimulation combined with non-verbal, art-based methods that allowed children to draw their traumatic memories rather than verbalise them. Delivered in a group format, the intervention aligned with communal understandings of healing prevalent in Middle Eastern cultures and reduced the stigma associated with individual therapy. Culturally resonant metaphors, such as references to migratory birds, helped explain trauma and resilience in child-friendly ways. Trained interpreters further enhanced the programme’s cultural appropriateness by adapting psychological language, advising on religious considerations, and bridging communication gaps between facilitators and participants.

These findings suggest that trauma-focused interventions, when adapted to local contexts and delivered by trained professionals, can significantly improve mental health outcomes even in acute and ongoing conflict environments such as Sudan, Palestine, and Syria.

Barriers to psychological support in crisis settings

Delivering mental health and psychosocial support in conflict zones faces a host of systemic and social barriers. In Northern Syria, overstretched health systems, stigma, and limited awareness have made mental health a low priority for both communities and local authorities.

In Gaza, services remain severely under-resourced, with widespread stigma, limited professional training, and severe shortages – Gaza had fewer than one psychiatrist per 100,000 people even before the current conflict.

In Sudan, caregivers and mental health professionals report that services are deprioritised by policymakers, making treatment scarce and often inaccessible. Similar issues affect Ukraine, where war-related trauma is compounded by stigma and lack of coordinated mental health care.

Rohingya refugees grapple with cultural and language barriers, lack of trained staff, unfamiliarity with cultural concepts of illness, and gender norms that affect service access. Mental health materials, delivery settings and interventions must be adapted to reflect Rohingya culture, language and diverse community needs to ensure trust, confidentiality and effectiveness.

In conflict settings, maintaining neutrality, protecting participant privacy, and ensuring safety for both staff and programme participants requires careful, context-sensitive decision-making that can shift rapidly with the security situation.

Conclusion

Mental health support in emergencies is not a secondary concern, it is a core part of effective humanitarian response. Humanitarian interventions must address both physical needs and mental wellbeing.

In camps, clinics and shelters, professionals use evidence-based therapies like CBT, EMDR and narrative exposure to help people process trauma. These methods are effective only when adapted to local cultures and contexts. What works in one place may not work in another. Mental health care must reflect local languages, beliefs and experiences. At the same time, crises are evolving.

To support people in conflict is to do more than provide food and shelter. It is to create space for safety, dignity and recovery. Mental health care is not something to be delayed until peace returns. It must be part of the response from the very beginning.

Farhan Rasool holds a master’s degree in psychology and works as a multidisciplinary writer.

Ruhee Zubair Khan is an accomplished counselling psychologist and founder of Yusra Wellbeing, known for blending evidence-based practices with humour and empathy.